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Lessons from the Ashley Smith inquest

Addressing the mental health needs of inmates helps this most vulnerable group and the safety needs of the public.

Ashley Smith at Joliette Institution in July 2007. She died three months later. (THE CANADIAN PRESS)

By Sandy Simpson

Sat., Jan. 26, 2013

The distressing images of the last moments of Ashley Smith’s life convey a stark message about the struggles that correctional officers have in caring for people with serious mental illness. This much-needed inquest will undoubtedly provide the public, politicians and the health and corrections sectors with much to reflect on, and much that must be improved.

Why do people with mental illness find themselves in prison? There are three main reasons.

It is sometimes the case that people with mental illness commit offences, just as other people in society do, and are held responsible for their actions. However, it can sometimes be the case that the social factors that increase offending (poverty, broken homes, trauma, substance misuse and the like) also increase the risk of developing a mental illness. For both these groups, mental illness did not cause the offending, but the individuals still require mental health care, especially if they suffer a relapse of illness while in prison. But even for these groups, proper access to mental health and other services may decrease the chances of offending in the first place.

Lastly, some people, when they are suffering a mental health crisis in the community, behave in ways where the police may be involved and criminal charges may follow. In this instance, their mental illness is causing the offending and they need a health response and a criminal justice response (if the offending is serious). These people may be found to be unfit to stand trial or not criminally responsible and are diverted from the criminal justice system into the health system via mental health courts and the forensic mental health system. Again, high-quality mental health services in the community are the best protection against people with mental illness getting into prison.

There is a small group of inmates who are more seriously unwell and not manageable by health and correctional staff in prison. Some of these persons need to be in a psychiatric hospital bed. Such access is very limited.

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It follows from this that we need sophisticated mental health services in prisons. For someone just remanded in custody on minor charges, this care will be focused on reconnecting them with community systems of care when they are out on bail or released. For sentenced inmates, care is aimed at supporting them in adjusting to their sentence and supporting them to maintain good mental health and engage in programs to ensure their risk of reoffending is decreased.

To achieve this, all inmates need to be screened for problems of mental illness; many conceal their problems or do not realize there is help available for them. Much care can be provided by the family physicians and clinics with mental health nurses and psychiatrists in the prison. Most inmates with major mental illness are stable and can live with appropriate care in prison, just as other inmates do, and as indeed, just as they would do if they were in the community.

Society owes a special duty of health care to those persons it chooses to incarcerate, especially those with major mental health problems. Failure to provide proper mental health care can lead to a cycle of increasingly disturbed behaviour resulting from the interaction of a vulnerable person and their environment. This can result in escalating periods of incarceration or punishment that only drives worsening behaviour.

Without such care, rates of suicide and violence within prison rise, and mentally ill persons are unable to access the in-prison rehabilitation programs they need to address the causes of their offending. Thus addressing the mental health needs of inmates helps this most vulnerable group and the safety needs of the public at the same time.

We see this same vicious cycle in the community, when a person who is struggling with mental health symptoms comes before a court and is given conditions of bail they are unable to meet, only to then incur more charges of having breached bail. Meanwhile, the person’s health needs have been missed or unaddressed, but criminal justice sanctions against them increase. This is likely to be ineffective, and unjust.

At the federal and provincial levels there is much work occurring to address these shortcomings and start filling the gaps in mental health provision to prison inmates. This needs to keep pace with the new demands: the forecast increase in prisoner numbers, increasing remand of prisoners with acute mental health needs, and complex interactions with substance misuse. Both the health and criminal justice sectors need to respond more comprehensively, and with greater humanity.

Sandy Simpson is chief of forensic psychiatry at the Centre for Addiction and Mental Health (CAMH), and head of the forensic psychiatry division at the University of Toronto.

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